Short handed during arrest

[Sizz]

How would you approach a "cardiac" arrest with a BLS partner and a driver?

How would you keep up with quality CPR while attempting any ALS?

One man CPR 30:2 on the BLS provider while you attempt a line and or attach the patches for a rhythm check/shock or quality 2 man CPR until you receive further help or arrive at the hospital?

I'm curious as to the best approach in a rural area with very limited support as well the few codes I've worked help had not been an issue.

 

[DesertMedic66]

Can the driver put one hand on top of the other and push hard and fast? (that can be the compression man while on scene). The BLS provider can BVM and airway adjuncts while the medic does IV, monitor, and intubate.

While enroute the BLS partner can pump chest. The medic can bag, push drugs, and shock if needed.

 

[Devilz311]

Can the driver put one hand on top of the other and push hard and fast? (that can be the compression man while on scene). The BLS provider can BVM and airway adjuncts while the medic does IV, monitor, and intubate.

While enroute the BLS partner can pump chest. The medic can bag, push drugs, and shock if needed.

Pretty much it. It's a little easier here with 2 medics; If we rendezvous with BLS enroute to the ER we can just kick the EMT out of the back (nicely worded, of course) and have two ALS providers during transport.

If it's my call and we're on scene, I'll just have my partner drop the tube while I start the line, and I'll just ride in with an EMT during transport. I can manage squeezing the BVM once every 5-6 seconds while pushing drugs and such.

 

[Handsome Robb]

This is why I like riding I/P. As an intermediate I can control the airway with a King, which is first line even for medics during an arrest, and set up the vent circuit or monitor/defib or IO/IV access or push arrest drugs. Most partners trade off duties. One does airway while the other gets the monitor setup and gets access then the next code it flops. We have crews run 2 person arrests, it's not the norm, usually we have a 4 person engine crew on scene with us. If it comes down to it we can have a bystander do compressions. With the qCPR device it's easy to tell them "keep the peaks inbetween these lines and keep that number at or above 100."

I have nothing against basics whatsoever I just feel like on an ALS 911 unit the I/P or P/P configuration works a bit better

 

[NomadicMedic]

We run the two person code here in DE all the time. We use the Lucas device for compressions, and EZ-IO for the access... bing, bang, boom.

Quick and easy.

 

[NYMedic828]

We run the two person code here in DE all the time. We use the Lucas device for compressions, and EZ-IO for the access... bing, bang, boom.

Quick and easy.

I had words from a supervisor 2 weeks ago because I made a quick check of the patients arms, which presented edemitis and went straight for the EZ-IO to save time putzing with an unlikely IV. Apparently I should have made atleast 3 attempts as per procedure before "wasting" an expensive IO needle. (EJ wasnt visible either as per my partner) Mind you the boss was an EMT (not knocking anyone) but don't tell me how to more efficiently manage my patient if you don't know jack...

Anyway, guys out here on Long Island actually ride 1 provider and the cops help do CPR and drive the bus. The provider is usually a CC or a Medic.

Friends who work for the county have told me they usually man the head, let the cops do CPR and they EJ/tube so they can do everything from the head.


Just a side note here, the absolute most important thing to keep as a priority during an arrest is quality CPR. Things like Pressors have not been provin in any clinical study to increase ROSC numbers. CPR is where its at. Keep blood flowing to vital organs. Obviously managing underlying causes if possible are a priority as well, but we rarely for a fact know the true cause of arrest while on scene.

 

[DrParasite]

How would you approach a "cardiac" arrest with a BLS partner and a driver?

three person crew? awesome. driver does compressions, BLS does BVM/OPA, medic does monitor, drugs, intubates if needed. Work them on scene, if you get them back, take em to the ambulance, if not, pronounce on scene.

How would you keep up with quality CPR while attempting any ALS?

BLS and driver do CPR, paramedic does ALS.

One man CPR 30:2 on the BLS provider while you attempt a line and or attach the patches for a rhythm check/shock or quality 2 man CPR until you receive further help or arrive at the hospital?

if I'm not mistaken (and i might be), good CPR and early defib will help a patient recover much better than ALS drugs.

I'm curious as to the best approach in a rural area with very limited support as well the few codes I've worked help had not been an issue.

if push comes to shove, call for additional help. FD/PD or a second EMS unit.

sometimes all you need is additional help carrying the patient out, or help on scene. do what you need to do.

 

[Shishkabob]

Partner does compressions while I do the ALS stuff, and when I'm not doing ALS stuff I'm doing compressions.


Did this fairly often when I worked rural.

 

[medicdan]

This is why I like riding I/P. As an intermediate I can control the airway with a King, which is first line even for medics during an arrest, and set up the vent circuit or monitor/defib or IO/IV access or push arrest drugs. Most partners trade off duties. One does airway while the other gets the monitor setup and gets access then the next code it flops. We have crews run 2 person arrests, it's not the norm, usually we have a 4 person engine crew on scene with us. If it comes down to it we can have a bystander do compressions. With the qCPR device it's easy to tell them "keep the peaks inbetween these lines and keep that number at or above 100."

I have nothing against basics whatsoever I just feel like on an ALS 911 unit the I/P or P/P configuration works a bit better

So for all intensive purposes, the P and I are interchangable on the arrest-- you both can perform any skills necessary (IV/IO, Monitor, defib, King, ET, ACLS meds, CPR)? If so, that's awesome.

 

[Handsome Robb]

So for all intensive purposes, the P and I are interchangable on the arrest-- you both can perform any skills necessary (IV/IO, Monitor, defib, King, ET, ACLS meds, CPR)? If so, that's awesome.

Yessiree

The only thing I can't do during is intubate but the king nullifies that. Manual defib, king airway and arrest drugs are all approved intermediate skills in the presence of the I's paramedic partner. Theoretically on a dual arrest we could each run our own and all I'd have to do was tell them what I'm doing and them to say ok. Only problem we have with that is we only have one monitor

Also I can't stop resuscitation efforts, that's gotta be the medic with OLMD approval.

 

[Commonsavage]

Wow! You've got a dedicated 3rd person on your codes:rofl:

 

[WuLabsWuTecH]

We have a really nice outline in our protocol for this, i've not typed out the full protocol, but the important steps:

Please note that the Basic/CFR is theoretical only, we do not allow a truck to leave the station with less than a full crew (defined as at least 2 basics) unless there is already another full crew enroute. The Basic/CFR was only put in because some of our FF's are not EMT's:

Basic/CFR or Basic/Basic:

CFR/Second Basic: Starts compressions
In Charge Basic: Manages Airway with BVM and O2. AED when appropriate. Intubation when appropriate. Switches Bagging and Compressions as needed.

NO Transport is allowed with just 2 crew members and we must wait for a driver to show up, or a second EMT in which case the man who is the least tired drives and the fresh EMT replaces him on compressions. This is true for any level of 2 people.

Basic/Intermediate:
Basic/Second Intermediate: Starts compressions
In Charge Intermediate: Manages Airway with BVM and O2. AED or Manual Defib when appropriate. Intubation when appropriate. Switches Bagging and Compressions as needed. A line is a distant priority (Intermediates do not have access to ACLS drugs) unless shock is indicated. An Intermediate may do an 12 lead, not really sure why, but it's never been done here.

Upon arrival of another Intermediate or Basic, the least tired person of the same level or below goes to drive.

Medic/Basic:
Basic is in charge of Airway, and AED setup.
Medic Starts on compressions.

When monitor is set up and airway established, Basic takes over compressions and medic starts trying to get a line and may change to manual defib.

If a second basic is on scene; then he starts compressions and the medic goes right to the medic skills. One of the advantages I've seen of the advaned airway curriculum in Ohio is that medics don't have to mess with combitubes and ETTs since either the basics will do it, or determine that a bag will be just as efficient for the time being.

I think our protocol for arrests is very well written. Based on who's on what position, everyone always knows what his role is in the resuscitation. Regardless of who's what level, you always know your role based on where you are sitting when the truck rolls, and order of arrival on scene.

This allows for a lot more efficient communications on scene and for things to be as standarized as possible.

For example, the last arrest I was on, I was person number 2, the driver was 3, and the medic was 1. The driver started compressions, the medic started medic stuff, I started airway and AED. When the fire truck showed up, the 2 EMTs switched into compressions and breathing for me and my partner to take a breather. The next medic pulls up and replaced one of the EMTs on airway while her partner got the cot. The entire way to the hospital, everyone knew what his or her role was and no one had to ask for anything to be done other than, "I'm getting tired, can we switch?"

 

[mycrofft]

Sizz, think it through, then innocently ask your boss or captain how he would do it, and then ask receiving hospitals how they would like it done, then all wide-eyed and innocent try to get these bodies of information together and see if they can address the shortage to begin with?

Your plan in the OP is about as good as it can get with your resources. "Standing and fighting", with those resources beyond maybe using the drivers to assist you while the basic attendant conducts CPR and hopefully AED before you load and go, could cross the "good use" versus "waste of" time line.

Maybe get more laypeople CPR trained to start it sooner before you arrive?

 

[Sizz]

Great replies everyone thank you,

All this feedback has been great as I've pondered this over and over just to challenge myself and what not. Basically assuming the "driver" is actually driving and we're en route to a facility when the code takes place and or we leave the scene working it as "possibly this one could be a save". Two in the back is much better than being alone on a transport / code situation although keep mind our transport times range from 30 to 90 minutes so it's a bit challenging.

Mycrofft I've actually addressed and gone through what you've suggested and it's turning out with a lot of valuable information. Thank you

So essentilay it's a 2 person code vs the 3 person as someone will have to drive

 

[usalsfyre]

Sizz, the answer to your question is not to transport cardiac arrest unless there's a ROSC. Even with three people you can't do effective CPR during transport.

 

[DrankTheKoolaid]

What us said. 20 minutes on scene, no jump in ETCO2 it's over. Call you OLMC if your protocols state you need to, and whatever doc you get on the phone would agree, 99.9999% of the time.

 

[Handsome Robb]

What us said. 20 minutes on scene, no jump in ETCO2 it's over. Call you OLMC if your protocols state you need to, and whatever doc you get on the phone would agree, 99.9999% of the time.

Especially with transport times being that long.

 

[NomadicMedic]

I was listening to the med radio the other morning. A crew was working an arrest and the medic painted a great picture to allow termination of efforts, going as far as to say "the patient was VERY asystolic..." (which made me laugh out loud...) End tidal wasn't above 7, 3 rounds of ACLS, never a shock...

The doc said, "transport him in..."

Ugh. What a waste of time and resources.

 

[DrankTheKoolaid]

re

sounds like a little insurance fishing on the ED docs part

 

[NomadicMedic]

I wouldn't say that... However I would say the transport was uncalled for.